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„_,Z.-0- :,, Affidavit in Support of Change to a Manufactured Home <br /> .:' "j.i= Department of Consumer and Business Services <br /> ; s9 Building Codes Division <br /> 1535 Edgewater St.NW, Salem, Oregon o Phone:503-378-4530 o Fax: 503-378-4101 <br /> Web: oregon.gov/bcd <br /> HOME INFORMATION <br /> Home ID number(if known): DMV X-plate number(if known): X188650 <br /> AFFIDAVIT INFORMATION - <br /> This affidavit can be used to support ownership changes without the applicant being required to submit legal documents <br /> and must be.submitted along with a Manufactured Home Ownership Document Application for New and Used Homes <br /> (440-2952)and a valid tax certification,signed by the county in which the home resides. <br /> APPLICANT/OWNERSHIP INFORMATION <br /> Applicant's name(last,first,middle):Brinlee, Mildred L Phone: <br /> Address:590 Rees Hill Road SE <br /> City:Salem State:OR ZIP:97306 <br /> Email: <br /> HOME INFORMATION <br /> Manufacturer: Fleetwood Year: 1985 - <br /> Serial number:WAFL2ABF16315971 HUD label numbers: <br /> ❑I am a co-owner of the manufactured home identified above and am listed with a right of survivorship with(list all <br /> owners) • <br /> I affirm that <br /> is/are deceased and that I possess a copy of the death certificate(s). <br /> 0 I affirm that if the buyer;new owner, or seller is a trust or conservatorship,that I am an authorized representative of <br /> the trust or conservatorship and that I have the legal standing to sign for the trust or conservatorship. <br /> ❑I affirm that,if ownership is transferring because of a divorce,I have been awarded sole ownership of this <br /> manufactured home and possess a copy of the court order with case number stating that award. <br /> ❑I affirm that I have power of attorney for: <br /> SIGNATURE <br /> I hereby attest that, to the best of my knowledge, this structure is free from all liens and claims of ownership, except as <br /> show in the attached ownership document application. I further attest that the information on this affidavit is true and <br /> correct. ° <br /> 1 <br /> Print name: /4/14 14.,k.R.:d L. Bim, I q.' • Signature: d... (- Q.sj ' <br /> State of vtr-enfi . <br /> County of 16 r!'I <br /> Signed and sworn to(or affirmed)before me on 9-71- 1 er (date)by� N <br /> ...,..a--------- <br /> Notary <br /> _(Notary seal) <br /> j��, ,, '; OFFICIAL STAMP <br /> DEPARTMENT OF ”"'�'`}' JAMES j'tl SKINNER <br /> CONSUMER '� NOTARY PUBLIC-OREGON <br /> �r� RVICES � ,' COMMISSION NO.989153 A SERVICES <br /> 440-5221(7/17/COM) MY COMMISSION EXPIRES JUNE 30,2023 <br />